RESULTS:
Sixty-five knees in 54 athletes were treated. Compared withusual care at 3 months, unaltered sport was more common in
bothdextrose-treated (21 of 21 vs 13 of 22; P .001) and lidocaine-treated(20 of 22 vs 13 of 22; P .034) knees, and asymptomatic sport
wasmore frequent in dextrose-treated knees than either lidocaine-treated(14 of 21 vs 5 of 22; P .006) or usual-care–treated (14 of 21
vs 3 of 22;P .001) knees. At 1 year, asymptomatic sport was more common
indextrose-treated knees than knees treated with only lidocaine
(32 of 38vs 6 of 13; P .024) or only usual care (32 of 38 vs 2 of 14;
P .0001).CONCLUSIONS:
Our results suggest superior symptom-reduction efficacy
of injection therapy over usual care in the treatment of Osgood-Schlatter
disease in adolescents. A significant component of the effectseems to be associated with the dextrose component of a
dextrose/lidocaine solution. Dextrose injection over the apophysis and
patellartendon origin was safe and well tolerated and resulted in
more rapidand frequent achievement of unaltered sport and asymptomatic
sportthan usual care. Pediatrics 2011;128:e1121–e1128 Osgood-Schlatter disease (OSD) is traditionally described as
“a traction apophysitis of the tibial tubercle because of repetitive
strain on the secondary ossification center of the tibial
tuberosity.”1 Advances in sequential radiographic examination have
helped to partially clarify pathology. Sequential knee ultrasound
imaging of tennis athletes going through puberty has demonstrated
that ossicles (separated cartilage that ossifies) within hypoechoic
cartilage are common and usually asymptomatic.2,3 An ossicle may
impinge on the patellar tendon, causing long-term impairment of
kneeling or running.4 However, a sequential
MRI study of adolescents with symptomatic OSD revealed 100% with
patellar tendon pathology and only 32% with ossicle formation.5
Improvement in patellar tendinosis was demonstrated in those that
became
asymptomatic, despite persistence of nonunion ossicles.5 Hirano et
al,6 in another sequential MRI study,
found that a partial tear of the secondary ossification center was
in place before patellar tendon swelling but
agreed that symptom resolution likely follows the resolution of
tendon changes. Thus, although repeated microavulsion fractures may
be the first radiographic finding and contribute to OSD pain and
pathology,6 they do not seem to be the primary source of pain and
dysfunction. 5,6 Recent MRI and ultrasound reports are also
consistent with a description of OSD as “a tendinopathy/ apophysosis
of the patellar tendon/tibial tubercle.”7–12 Safety and level A–C
evidence of efficacy
(per US Preventive Services Task Force criteria) of injection of 10%
to 25% dextrose in areas of damaged ligament, tendon, and cartilage
in adults has been demonstrated in randomized controlled trials in
Achilles tendinosis,
13 finger osteoarthritis,14 knee osteoarthritis, 15 lateral
epicondylosis,16 sacroiliac joint pain,17 and in case series
collections of patients with Achilles degeneration,18,19 anterior
cruciate ligament laxity,20 coccygodynia,21 hip adductor and
abdominal tendinosis,22 and plantar fasciosis.23 There are no
previous reports of application of dextrose injection in a strictly
pediatric population, nor are there reports of injection about an
apophysis where, as described, the source of pain and pathomechanism
are not yet clear. The common counsel that parents receive is that
OSD is “a self-limited process that responds favorably to
conservative treatment.”24 The self-limit is closure of the tibial
growth plate, and thus the period of potential symptoms can be
considerable.1 A succinct recent description of conservative
treatment includes “rest, icing, activity modification, and
rehabilitation exercises.”
1 Use of a knee strap may protect the tibia from painful contact,
but no prospective trials have been reported.
25 Symptoms typically wax and wane for months to years.26 Gerulis et
al,27 reporting on 178 conservatively
treated adolescents, found a mean range of 13 to 16.5 months of pain,
depending on whether load restrictions were followed. Mital et al28
reported that, after a mean of 3.8 years of symptoms and
conservative treatment, 12% of subjects merited surgery. Sixteen
years later, Hussain and Hagroo29 reported a 9% surgical rate after
a conservative therapy trial. In young adults seen for OSD who
received conservative treatment only, telephone interview data a
mean of 9 years after diagnosis revealed a 60% incidence of kneeling
discomfort and 18% incidence of sport limitation because of pain
over the tibial tubercle.30 Air Force cadets with an OSD history
reported more frequent anterior knee pain and significantly
diminished Sports Activity Scale scores than a cohort with no OSD
history.31 Alteration of primary sport choice, altered peer group
dynamics, self-esteem effects, and occasional withdrawal from all
competitive sports are effects of OSD that have not been measured
prospectively. Reassuring parents and athletes that OSD is time-limited
is appropriate, but dismissing it as benign in effect or brief in
duration seems to be at odds with
available literature. In current literature, OSD is depicted as a
condition involving degeneration of both tendon and apophyseal
tissue, as opposed to an isolated inflammation of the apophysis.
Dextrose injection has been found to be safe and potentially
effective in treatment of cartilage and tendon degenerative
disorders.
The purpose of this study was to examine the potential of dextrose
injection versus lidocaine injection versus supervised usual care to
reduce sport-related symptoms in adolescent athletes with OSD. The
hypothesis was that dextrose injection would be superior to either
lidocaine injection or supervised usual care.

Objective: To determine the efficacy of simple dextrose
prolotherapy in elite kicking-sport athletes with chronic groin pain
from osteitis pubis and/or adductor tendinopathy.Design: Consecutive case series.Setting: Orthopedic and trauma institute in Argentina.Participants: Twenty-two rugby and 2 soccer players with
chronic groin pain that prevented full sports participation and who
were nonresponsive both to therapy and to a graded reintroduction
into sports activity.Intervention: Monthly injection of 12.5% dextrose and 0.5%
lidocaine into the thigh adductor origins, suprapubic abdominal
insertions, and symphysis pubis, depending on palpation tenderness.
Injections were given until complete resolution of pain or lack of
improvement for 2 consecutive treatments.Main Outcome Measures: Visual analog scale (VAS) for pain
with sports and the Nirschl Pain Phase Scale (NPPS), a measure of
functional impairment from pain.Results: The final data collection point was 6 to 32 months
after treatment (mean, 17mo). A mean of 2.8 treatments were given.
The mean reduction in pain during sports, as measured by the VAS,
improved from 6.3 1.4 to 1.0 2.4 (P .001), and the mean reduction in
NPPS score improved from 5.3 0.7 to 0.8 1.9 (P .001). Twenty of 24
patients had no pain and 22 of 24 were unrestricted with sports at
final data collection.Conclusions: Dextrose prolotherapy showed marked efficacy for
chronic groin pain in this group of elite rugby and soccer athletes.Key Words: Athletic injuries; Glucose; Groin; Growth
substances; Osteitis; Rehabilitation; Sports medicine; Tendinitis;
Tendons.

Abstract:

Objective: To obtain multisport and
long-term outcome data from the use of regenerative injection
therapy on career-threatened athletes.

Design: Consecutive enrollment of elite
performance-limited athletes with chronic groin/abdominal pain who
failed a conservative treatment trial. The treatment consisted of
monthly injections of 12.5% dextrose in 0.5% lidocaine in abdominal
and adductor attachments on the pubis. Injection of the nociceptive
source was confirmed by repetition of resistive testing 5 mins after
injection.

Results: Seventy-five athletes were
enrolled. Seventy-two athletes (39 rugby, 29 soccer, and 4 other)
completed the minimum two-treatment protocol. Their data revealed a
mean groin pain history of 11 (3-60) mos. Average number of
treatments received was 3 (1-6). Individual paired t tests for
Visual Analog Scale (VAS) of pain with sport (VAS Pain) and Nirschl
pain phase scale measured at 0 and an average of 26 (6-73) mos
indicated VAS Pain improvement of 82% (P < 10-10) and Nirschl pain
phase scale improvement of 78% (P < 10-10). Six athletes did not
improve following regenerative injection therapy treatment, and the
remaining 66 returned to unrestricted sport. Return to unrestricted
sport occurred in an average of 3 (1-5) mos.

Conclusions: Athletes returned to full
elite-level performance in a timely and sustainable manner after
regenerative injection therapy using dextrose.